Continuity of Care: Pneumonia: Targeting Treatments and Monitoring the Response

Cheryl A. Grandinetti, PharmD
Published Online: Saturday, November 1, 2008
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Dr. Grandinetti is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Rockville, Maryland. The views expressed are those of the author and not those of any government agency.


Infected or inflamed lung parenchyma is generally described as community-acquired pneumonia (CAP) or nosocomial pneumonia (NP).1-3 Influenza and pneumonia combined is the seventh leading cause of death in the United States. Pneumonia-associated mortality remains high in patients who are elderly, critically ill, immunocompromised, and with preexisting cardiopulmonary disease.1,4

Types of Pneumonia

Table
Pneumonia Risk Factors

Alcoholism

Chronic liver or lung disease

Smoking

Heart failure

Coronary artery disease

Dementia

Diabetes

Drug abuse

Elderly

Immunosuppression

Malignancy

Medications that alter consciousness

Renal failure

Seizures

Strokes

Additional risk factors for NP and NHAP

Dysphagia

Enteral feedings

Impaired mental status

Inadequate oral care

Malnutrition

Medication or therapies that impair lung defenses

Medications that reduce gastric acidity (ie, proton pump inhibitors, histamine2 antagonists)

Nasogastric and endotracheal tubes

Surgery

Trauma

NP = nosocomial pneumonia; NHAP = nursing home?acquired pneumonia.
Adapted from references 2,4,5.

Each type of pneumonia is associated with causative bacteria, viruses, parasites, or fungi with unique clinical presentations but similar risk factors. Difficulty obtaining sputum samples and results confounded by oropharyngeal colonization make identifying the causative microorganism difficult. Antimicrobial therapy, therefore, is often empiric.5,6

Community-Acquired Pneumonia
CAP is acquired more than 14 days from a stay in a hospital or long-term care facility. Most CAP patients can be treated safely as outpatients, and mortality is <5%; however, some patients needing close observation, respiratory support, or intravenous (IV) antibiotics require admission to the hospital. Mortality approaches 40% in patients who require intensive care. Prompt treatment (within 4 hours of admission) can improve mortality.1,7,8

Nosocomial Pneumonia
NP, occurring 48 hours or more after hospitalization, is the leading hospital-acquired cause of mortality. NP includes ventilator-associated pneumonia and health care?associated pneumonia (HCAP). HCAP occurs in patients who were hospitalized in an acute care hospital for ≥2 days within 90 days of infection; resided in a long-term care facility; received IV antibiotics, chemotherapy, or wound care within 30 days of infection; or attended a hospital or hemodialysis clinic. Recent antibiotic therapy, hospitalization (within 3 months), and late-onset NP (≥5 days after admission), increase the risk for colonization with a multidrug resistant (MDR) organism.2,5,9,10

Nursing Home?Acquired Pneumonia
Nursing home residents are at greater risk for pneumonia with antibiotic-resistant organisms, and pneumonia is the leading cause of death among residents.2 The elderly are prone to conditions causing aspiration and reflux (ie, oversedation, excessive narcotic use, supine positioning, and confusion). Respiratory care interventions and good oral care are important to reduce oropharyngeal colonization with potential respiratory pathogens that can be aspirated.

Monitoring and Counseling Tips for Pharmacists

In All Settings:

  • Recommend antibiotics with longer half-lives that permit once-daily administration, improve adherence and outcomes, and decrease costs
  • Counsel patients on:
    • Completing entire treatment course
    • Maintaining adequate nutrition and exercise for recovery and to prevent subsequent infections
    • Preventing and spreading CAP: hand washing, using masks or tissues, and vaccinations
    • Smoking cessation programs, if applicable
  • Assess adherence

In the Hospital:

  • Ensure accurate pneumonia diagnosis
  • Recognize patients at risk for MDR
  • Ensure use of most appropriate, safe, and cost-effective antibiotic; avoid indiscriminate antibiotic use
  • Administer antibiotics as early as possible
  • Assess vaccination status
  • Switch patients to oral therapy when clinically indicated
  • Discharge patients as soon as they are clinically stable

At Discharge:

  • Vaccinate at discharge or during outpatient treatment
  • Remind patients of the importance of annual influenza vaccine

In Long-Term Care Facilities:

  • Emphasize the importance of good oral hygiene
  • Use central nervous system depressants cautiously

CAP = community-acquired pneumonia; MDR = multidrug resistance. Adapted from references 2,4-6.



Treatment

Treatment goals are to eradicate causative pathogens, resolve clinical signs and symptoms, minimize hospitalization, and prevent reinfection. The Infectious Diseases Society of America/American Thoracic Society consensus guidelines recommend empiric therapy with macrolides, fluoroquinolones, or doxycycline.4-6 The Centers for Disease Control and Prevention recommends fluoroquinolone use only when patients fail first-line regimens, are allergic to alternative agents, or have a documented drug-resistant pneumococcal infection. Clinicians should consider local epidemiologic and resistant patterns and patient circumstances when basing therapy choices on published guidelines.5,6

Prolonged and unnecessary broad-spectrum anti-infectives are associated with development of resistant organisms. Clinicians should avoid antibiotic overuse and tailor empiric treatment to the causative microorganism as soon as possible. Antibiotics are generally administered for 7 to 14 days; longer treatment durations may be necessary in immunocompromised patients or those infected with atypical pathogens (Legionella pneumophilia, Mycoplasma pneumoniae, Chlamydia pneumoniae). Oral therapy is indicated once patients are clinically stable and able to tolerate oral intake.1,7,9

Preventive Strategies

For patients ≥50 years of age, those with chronic medical conditions, long-term care facility residents, household contacts of high-risk persons, and health care workers, annual vaccination with inactivated influenza vaccine is crucial. The intranasal live attenuated vaccine is indicated for healthy persons aged 5 to 49 years. A one-time pneumococcal vaccine is indicated for patients aged ≥65 and younger patients who are immunocompromised or have long-term medical conditions.11

Pharmacists can influence patient care by ensuring that therapy is initiated quickly with the most appropriate, cost-effective anti-infective, monitoring patient response, and suggesting conversion to oral therapy to shorten hospitalization.

Table
Risk Factors for Multi-Drug Resistant Pathogens

Hospitalization for ≥2 days or antimicrobials in preceding 90 days

Current hospitalization of ≥5 days

High frequency of antibiotic resistance in the community or specific hospital unit

Resident in extended care facility

Home infusion therapy

Chronic dialysis within 30 days

Home wound care

Family member with MDR pathogen

Immunosuppression

MDR=multidrug resistant
Adapted from reference 5.

Table
Empiric Therapy Choices for Pneumonia Treatment

Types of Pneumonia

Patient Type and Setting

Common Pathogens

Empiric Therapy Recommendations

CAP

Previously healthy outpatients, no risk factors for MDR pathogens

Streptococcus pneumoniae; Haemophilus influenzae; Mycoplasma pneumoniae; Chlamydia pneumoniae; Moraxella catarrhalis; Staphylococcus aureus

Azithromycin, clarithromycin, or erythromycin
Alternatives: doxycycline

Outpatients with comorbidities or macrolide-resistant infection

Fluoroquinolonea or high-dose amoxicillin or amoxicillin/clavulanate plus a macrolide or doxycycline
Alternatives: ceftriaxone, cefpodoxime, and cefuroxime plus a macrolide or doxycycline

Inpatient, non-ICU treatment

S pneumoniae; M pneumoniae; C pneumoniae; H influenzae Legionella species

Fluoroquinolone,a beta-lactam (cefotaxime, ceftriaxone, or ampicillin; ertapenem for selected patients) plus a macrolide or doxycycline
Penicillin-allergic patients: fluoroquinolonea

Inpatient, ICU treatment

S pneumoniae; S aureus; Legionella pneumophilia; Gram-negative bacilli; H influenzae; Pseudomonas aeruginosa

Cefotaxime, ceftriaxone, or ampicillin-sulbactam plus azithromycin or fluoroquinolonea
Penicillin-allergic patients: fluoroquinolonea and aztreonam
For pseudomonas infection: piperacillin/tazobactam, cefepime, imipenem, or meropenem plus ciprofloxacin or levofloxacin
OR beta-lactam plus an aminoglycoside and azithromycin or fluoroquinolonea; penicillin-allergic patients: substitute aztreonam for a beta-lactam.
For MRSA infection: add vancomycin or linezolid.

Viral CAP

Outpatient/inpatient non-ICU treatment

Influenza; Respiratory syncytial virus; Adenovirus; Parainfluenza virus

Oseltamivir, zanamavir (within 48 hours of the onset of symptoms)
Alternatives: amantadine, rimantadine

NHAP

Nursing home

Klebsiella pneumoniae; S aureus; Escherichia coli; MRSA; Anaerobes

Fluoroquinolone or amoxicillin/clavulanate plus azithromycin or clarithromycin

Hospital ward

Parenteral third-generation cephalosporin or ampicillin/sulbactam plus azithromycin or clarithromycin or parenteral levofloxacin, gatifloxacin, or moxifloxacin

NP, VAP, HCAP

Early onset, no risk factors for MDR pathogens, any disease severity

S pneumoniae; H influenzae; Methicillin-sensitive S aureus; Antibiotic-sensitive enteric gram-negative bacilli; E coli; K pneumoniae; Enterobacter species; Proteus species; Serratia marcescens

Ceftriaxone, levofloxacin, moxifloxacin, ciprofloxacin, ampicillin/sulbactam, or ertapenem

Late-onset disease or risk factors for MDR pathogens

All microorganisms listed under early onset plus MDR pathogens:
P aeruginosa; E coli; K pneumoniae; Acinectobacter species;
MRSA;
Legionella species

Cefepime, ceftazidime, imipenem, meropenem, or piperacillin/tazobactam,
plus
Ciprofloxacin, levofloxacin, or aminoglycoside
plus
If MRSA+: linezolid or vancomycin
If legionella+: replace aminoglycoside with a macrolide or a fluoroquinolone

*The Infectious Diseases Society of America recommends moxifloxacin, gemifloxacin, and levofloxacin. Avoid ciprofloxacin and ofloxacin because they lack activity against S pneumoniae.
CAP = community-acquired pneumonia; HCAP = health care associated?pneumonia; ICU = intensive care unit; MDR = multidrug resistant; MRSA = methicillin-resistant Staphylococcus aureus; NP = nosocomial pneumonia; NHAP = nursing home?acquired pneumonia; VAP = ventilator-associated pneumonia.
Adapted from references 2,5,6.



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